Fill and Sign the Change in Family Coverageoffice of Human Resources Form

Change of Family Status Request Form This form must be submitted to the Human Resources Department within 30 days of the change in your status. The Human Resources Department will review your request and make a determination as to whether the request is appropriate.Name (Please Print): Social Security Number: Address: Check one of the following changes in status events that you have experienced: Change in legal marital status (marriage, divorce, legal separation, death of spouse) Change in number of tax dependents (birth, adoption, placement for adoption, death) Commencement or termination of employment by you, you’re your spouse or your dependent Change in work schedule (becoming eligible/ineligible for insurance because of reduction or increase in hours worked by you, your spouse or your dependent; strike or lockout) Dependent meets or ceases to meet dependent eligibility (reaches limiting age, loses or gains student status, marriage) Change in residence or worksite of you, your spouse or your dependents (moving in or out of HMO area) Other Date of the change in status event checked above: I have read and fully understand the regulations to change my election. I understand that my new Enrollment/Change Form and this Change in Status Form must be completed within 30 days of the change in status event, and the election change I haverequested must be consistent with the change in status event. I certify that the aboveinformation is true and correct, and agree to provide any necessary documentation toverify the change in status event. Cancellations must be received by the 15th of themonth to be effective the first of the next month. If changing from single to family (orfrom family to single) the insurance change form needs to be received in the Benefitsoffice by the 10th of the month to be effective the first of the next month.Employees Signature: _________________________________ Date: _______________